The transformation of community hospitals through the transition to value-based care: Lessons from Massachusetts

Transcription

1 Boston University OpenBU School of Social Work BU Open Access Articles 2017 The transformation of community hospitals through the transition to value-based care: Lessons from Massachusetts Louis, Christopher Christopher Louis, Sara Bachman, Dylan Roby, L Melby, David Rosenbloom "The transformation of community hospitals through the transition to value-based care: Lessons from Massachusetts.." The American Journal of Accountable Care, Volume 5(4):26-30, Issue 5, pp (5). Available online: Boston University

2 REFORM TRENDS Transitioning Community s to Value-Based Care: Lessons From Massachusetts CHRISTOPHER J. LOUIS, PHD, MHA; SARA S. BACHMAN, PHD, MS; DYLAN H. ROBY, PHD; LAUREN MELBY, MBA, MPP; AND DAVID L. ROSENBLOOM, PHD ABSTRACT Enabling community hospitals to provide efficient and effective care and maintain competition on par with their academic medical center (AMC) counterparts remain challenges for most states. Advancing accountable care readiness adds to the complexity of these challenges. Community hospitals experience narrower operating margins and more limited access to large populations than their AMC counterparts, making the shift to value-based care difficult. Massachusetts has taken legislative action to ensure a statewide focus on reducing healthcare costs, which includes a nearly $120-million grant program supporting community hospital and system transformation toward a value-based environment. The Massachusetts Health Policy Commission s Community Acceleration, Revitalization and Transformation (CHART) investment program is the state s largest effort to date aimed at readying community hospitals for value-based care. In doing so, Massachusetts has created the largest state-driven, all-payer (payer-blind) readmission reduction initiative in the country. In this paper, we examine the design and evolution of CHART Phases 1 and 2 and offer insights for other states contemplating innovative approaches to bolstering community hospital participation in value-based care models. The American Journal of Accountable Care. 2017;5(4):26-30 What are states doing to prepare community hospitals for value-based care models? For more than a decade, many US states have experienced widening of the healthcare price, resource, and performance gaps between academic medical centers (AMCs) and community hospitals. Scholars point to greater service intensity for the treatment of similar patients, graduate medical education costs, and research expenses as the primary drivers of these gaps. 1 Health system consolidation further exacerbates this issue as AMCs gain reimbursement negotiation clout through membership in large health systems. 2 AMCs and affiliated physician groups have benefitted most from these trends, achieving improved strategic positioning among larger population bases and financial prosperity compared with many of their community hospital counterparts. These competitive advantages were recently used as a vehicle to become early adopters of value-based payment (VBP), a strategy used by purchasers to facilitate cost-effective care delivery and improved quality, emphasizing a shift from fee-forservice to outcomes-based payment. Numerous payment and delivery system paradigms have been implemented since the inception of the Affordable Care Act, including bundled payments, accountable care organizations (ACOs), and integrated care systems that link primary care and behavioral health services, among others. This national trend presents an added challenge for community hospitals in maintaining pace with overall market competitiveness and innovation of AMCs. To combat these trends, some states, such as Massachusetts, have sought the help of policy makers in taking legislative action to promote community hospitals efforts to shift to value-based care and alternative payment models (APMs). 26 / The American Journal of Accountable Care

3 Massachusetts has been nationally recognized for its progressive healthcare reform policies, including the 2006 healthcare reform law, Chapter 58, which established the Massachusetts health insurance exchange and offered many residents free or subsidized insurance. These policies helped the state achieve a 2007 uninsured rate of less than 6% among the nonelderly population, the lowest rate in the country. 3 In addition to increasing insurance coverage, this reform was associated with lower all-cause mortality. 4 Nevertheless, healthcare spending in Massachusetts continued to grow, outpacing the US economy. By 2009, the state had the highest per capita healthcare expenditures ($9278 vs national average of $6815) in the nation. 5 Massachusetts also compared poorly to the United States on Medicare readmissions, and approximately half of its emergency department (ED) visits were potentially avoidable. 6 The combination of increased prices at large systems and a shift toward utilization of AMCs (vs community hospitals) contributed to rising overall costs. 7 As Massachusetts residents increasingly sought inpatient care at branded higher-cost AMCs, community hospital revenue bases and operating margins deteriorated, and these lower-cost hospitals ability to engage in strategic initiatives (such as investing in health information technology [IT] and employing physicians) suffered. Based on these disparities in care settings, Massachusetts legislators sought further policy-level action to drive change. In 2012, the legislature passed Chapter 224, the state s landmark costcontainment law, which established a focus on improving the quality of health care and reducing costs through increased transparency, efficiency and innovation. 8 Chapter 224 sought to promote new health reform strategies to limit healthcare spending growth to potential gross state product, or 3.6% annually, and move away from fee-for-service payments. Strategies within Chapter 224 include: 1) actively monitoring cost growth and markets, 2) the widespread adoption of APMs by public and private payers, 3) a focus on wellness and prevention, and 4) increased price transparency for consumers. 8 One of the new entities established by Chapter 224 to implement these strategies is the Health Policy Commission (HPC). An independent state agency, the HPC is governed by an 11-member Board of Commissioners composed of public and private sector leaders appointed by the governor, attorney general, and state auditor. The HPC s mission is to advance a more transparent, accountable, and innovative health care system through independent policy leadership and programs with the goal of better health and better care at a lower cost across Massachusetts. 9 The HPC fosters a value-based marketplace through independent policy leadership, provider certification programs, and targeted investments. Chapter 224 authorized the HPC to administer several investment programs, the largest of which is the Community Acceleration, Revitalization and Transformation (CHART) investment program. CHART is a phased investment program that reinvests nearly $120 million, initially funded by a 1-time assessment on large Massachusetts health systems and commercial payers, into certain community hospitals to enhance delivery of efficient, effective care and prepare them to achieve success in a value-based environment. 10 In this paper, we examine the structure of the CHART investment program, offer insights from the design of CHART Phases 1 and 2, and provide lessons learned that can be redeployed by other states seeking to transform healthcare delivery among their community hospitals. The CHART Investment Program To support community hospitals in advancing value-based care readiness, CHART provides a roadmap to develop capacities and capabilities for innovative approaches to care delivery. The goals of the CHART program, as defined in Chapter 224, are to: 1) improve and enhance the ability of community hospitals to serve populations efficiently and effectively, 2) advance the adoption of health IT, 3) accelerate the ability to electronically exchange information with other providers in the community to ensure continuity of care, 4) support infrastructure investments necessary for the transition to APMs, 5) aid in the development of care practices and other operational standards necessary for certification as an ACO, and 6) improve the affordability and quality of care. 8 To achieve these goals, the HPC structured the CHART program in multiple phases over several years to allow awardees to transition from short-term care delivery improvement initiatives to longer-term preparation for VBP. CHART Phase 1 ($9.2 million, 28 awardees, February 2014 to September 2014) focused on short-term, high-need initiatives to build capacity. CHART Phase 2 ($60 million, 25 awardees, September 2015 to February 2018), a 2-year program with staggered program start dates, aims to support the transformation of community hospitals in their delivery of efficient and effective care. To be considered eligible to receive CHART funding, hospitals must meet specific criteria established as part of Chapter 224. CHART-eligible acute care hospitals are: 1) nonprofit community hospitals, 2) nonteaching hospitals, and 3) relatively low priced. 7,11 At the time of CHART Phase 1 procurement, 31 of Massachusetts 80 hospitals (3 have closed since 2013) satisfied the eligibility criteria. CHART Phase 1: Foundational Investments for Transformation. Planning for CHART Phase 1 began in mid-2013, with the request for proposals (RFP) released in October This initial phase of foundational investments was targeted toward providing support for shortterm infrastructure expenditures to facilitate hospital and system transformation. Phase 1 projects were grouped into 3 pathways: 1) rapid-cycle pilots aimed at improving quality or reducing costs, 2) capability and capacity building, and 3) planning for operational improvement geared toward hospital and system transformation. 12 As part of the application process, each hospital identified specific process, quality, and financial metrics that would be evaluated at regular intervals throughout Phase ajmc.com / 27

4 REFORM TRENDS 1. Metrics varied based on the context of each project. HPC provided technical assistance (TA) in the form of implementation consultation and clinical expertise to each hospital awardee. eappendix Table 1 (eappendices available at ajmc.com) provides a summary of the CHART Phase 1 hospital awards by funding amount. Approximately $9.2 million was awarded to 28 acute care community hospitals during Phase Award amounts ranged from a minimum of $65,000 (Beverly ) to a maximum of $500,000 (Holyoke Medical Center). projects focused on a range of clinical and operational areas, including hospital utilization and care coordination (n = 18 projects; eg, inpatient and outpatient diabetes care coordination among patients with high utilization), technology enhancements (n = 16; eg, planning for health information exchange connectivity), behavioral health (n = 8; eg, improvements in behavioral health case management in the ED), and patient safety and education or process improvement (n = 7; eg, implementation of a high-risk intervention team that provides patient education, medication management, and discharge planning to patients with complex chronic illnesses). Many hospitals implemented more than 1 project as part of their CHART Phase 1 award. CHART Phase 2: Driving System Transformation. Lessons from CHART Phase 1 informed the design and implementation of CHART Phase 2, which sought to build upon the Phase 1 foundation by transforming the healthcare delivery system and calling for a paradigm shift in the community hospitals approach to care delivery. The HPC identified 3 outcomes-oriented aims for CHART Phase 2: 1) maximize appropriate hospital use, 2) enhance behavioral health care, and 3) improve processes to reduce waste and improve quality and safety. 14 The HPC released the CHART Phase 2 RFP in June 2014 and received 30 (out of a possible 31) prospectuses. Proposals were submitted in September 2014, awards were given the following month, and a robust yearlong iterative and collaborative implementation planning period began. As a result of this process, 25 projects (20 individual hospital projects and 5 multihospital projects) were ultimately approved and funded. CHART Phase 2 initiatives launched on a rolling basis beginning in September 2015, and by February 2016, all 25 awardees had initiated their 24-month Phase 2 projects. eappendix Table 2 provides a summary of each CHART Phase 2 award by hospital, project, primary project aim statement, and funding amount. In all, nearly $60 million was deployed to fund 25 programs, with funding amounts ranging from $900,000 (Baystate Franklin Medical Center, Baystate Noble, and Baystate Wing Joint Award) to $8 million (Southcoast s Group Joint Award). 15 projects ranged in focus, including high-risk care teams using integrated technology, services for behavioral health patients presenting in the ED, and the integration of services across multiple outpatient care settings. CHART Phase 2 program aims primarily focused on reducing 30-day readmission rates (n = 16) and reducing ED utilization (n = 11). 16 CHART Phase 2 incorporated more emphasis on reporting and TA compared with Phase 1. In Phase 2, approximately 30 metrics were collected from each hospital awardee each month. Metrics reflect utilization (eg, readmission rates) and operational efficiency (eg, ED length of stay for behavioral health patients). TA was enhanced in Phase 2 to include at least monthly conversations between HPC program officers and hospital staff. These conversations were used as an ongoing vehicle for providing project updates (eg, staffing changes), identifying project risks, and helping awardees form strategies to overcome barriers. At the beginning of Phase 2, TA was focused on start-up implementation issues (eg, data collection and design, reporting, project organization, etc), but over time became more focused on the dissemination of best practices and learning across sites. Quarterly regional and biannual statewide meetings of hospital awardees led by HPC consultants and staff were held to share best practices and help address similar issues occurring at multiple hospitals. Clinically-trained expert consultants and HPC staff regularly visited each hospital site to discuss progress toward CHART Phase 2 aims and facilitate goal achievement. Learning From the Design of CHART Phases 1 and 2 The HPC s CHART investment program is designed to transform care delivery at Massachusetts community hospitals (and in their surrounding communities), thereby preparing these organizations for VBP. In doing so, Massachusetts has created the largest statedriven combined all-payer (payer-blind) inpatient readmission and ED utilization reduction program in the country. Further, CHART is implemented at-scale. Care is delivered to entire target populations, rather than subsets of those populations, through pilot programs. Given the CHART program s design and scale, thriving partnerships between state health policy makers, the HPC, hospital staff, and community partners are critical to program success. Although the CHART investment program is not a one-size-fitsall program, other states can learn from Massachusetts and deploy elements of CHART. Drawing on lessons from CHART Phases 1 and 2, we offer recommendations for states considering how to transform care delivery in their community hospitals to promote VBP: Use legislation to drive change. Massachusetts policy makers committed to changing the trajectory of healthcare spending through Chapter 224. Through action-oriented statutory language, Massachusetts instituted an annual maximum healthcare spending target, created the HPC to monitor progress against this benchmark and develop associated policies and programs, and levied an assessment on certain providers and insurers to support CHART. Ensure appropriate funding levels. Funding levels for specific community hospital grants must be substantial enough to enable innovation. CHART Phase 1 increased capacity and capability through smaller investments; Phase 2 built on that momentum with larger, more broad-ranging transformational investments in specific hospital projects. 28 / The American Journal of Accountable Care

5 Engage in a collaborative implementation planning process. CHART Phase 2 awardees engaged with the HPC in a robust, iterative, yearlong implementation planning process to develop innovative and transformative projects. Thus, projects were more closely tailored to the local hospital context and specific population needs. This enhanced project quality and adaptability and aligned hospital and state goals. Develop an ongoing measurement plan that informs program design, implementation, and adaptation. Funders and awardees should collaborate to develop a measurement plan that captures only measures that are salient to understanding program effectiveness and areas for process improvement. In CHART Phase 2, locally-derived data were used to drive program design. Throughout implementation, hospital awardees and HPC staff used key utilization, process, and outcomes data to drive real-time improvement and program adaptation. Deploy ongoing flexible technical assistance to awardees throughout planning and implementation stages. In CHART Phase 2, TA occurred through regular meetings with HPC program officers, regional and statewide learning collaboratives, and special sessions with expert consultants. The HPC retained flexibility in the provision of TA, adapting based on cohort-wide and individual awardee needs and performance. Involve clinical and nonclinical community partners from the beginning. Through their CHART programs, several hospitals have engaged in coalition building and created multistakeholder collaborative meetings that include community partners in regular hospital team meetings. Engaging key community partners (eg, police departments, skilled nursing facilities, detox centers) in implementation planning may improve the ability of awardees to more rapidly implement and integrate their projects. Engage an external evaluator to assess program efficacy. The HPC has engaged an independent evaluator to perform a full-scale, mixed-methods evaluation of CHART Phase 2. Examining the perspectives of key stakeholders as well as broader trends in hospital and state data promotes a comprehensive view about whether specific hospital investments advance community hospitals participation in VBP. DISCUSSION States seeking to transform low-cost community hospitals toward value-based care must find ways to incentivize participation in activities that reflect these new delivery models. One of the most notable efforts to transform care in states is the State Innovation Models initiative funded by the Center for Medicare and Medicaid Innovation. However, these federally funded projects are not specifically focused on community hospitals and are interested primarily in Medicare and Medicaid 17 Other state-driven programs focus on specific issues, such as reducing avoidable healthcare utilization (eg, readmissions). For example, the Texas Medical Center Grant Program in Collaborative Health Policy Research awards $750,000 annually to hospital-based projects aiming to benefit the health of Texans through improving care for at-risk populations and reducing hospital readmissions. 18 New York implemented the Value-Based Payment Quality Incentive Program in conjunction with its Delivery System Reform Incentive Payment (DSRIP) program to transition financially distressed facilities [community hospitals] to VBP, improve their quality of care and as a result, achieve financial sustainability. 19 The design of the New York DSRIP program also includes some components similar to those of CHART Phases 1 and 2, such as project-based initiatives and community partner engagement. 20 However, no state-based investment program using nonfederal funds has used such a robust and collaborative design as CHART. Thus, the innovative roadmap created by Massachusetts should be considered by policy makers when determining how best to design the specific path forward given their own state s context. Although CHART targets community-based populations, it is also aligned with publicly sponsored reforms, such as Medicaid Section 1115 waivers. Massachusetts new 1115 waiver, effective July 2017, authorizes $52.4 billion to be spent over 5 years and includes $1.8 billion in DSRIP investments to support providers in transitioning to ACOs and enhancing behavioral health care and long-term services and support. 21 The waiver also enables Massachusetts to implement its MassHealth (Medicaid) ACO program. In order to ensure programs are complementary to each other, the HPC actively works with other state agencies to be supportive of, but not duplicative of, these initiatives. A broader question that looms for federal and state health policy makers is whether APMs and value-based care delivery models can be sustained at community hospitals in the long term. With challenges like narrower financial margins, reliance on public payers, fewer employed physicians, and older facilities compared with their AMC counterparts, community hospitals face substantial barriers to shifting to and sustaining APMs and accountable care models. These are relevant issues ripe for future research and inquiry. Nonetheless, Massachusetts seems to have acknowledged these challenges and continues to move forward despite the fact that a broader state and federal payment system shift to value-based care has not occurred as quickly as initially anticipated. Moreover, with federal health policy in flux, statebased efforts to innovate within their community hospital systems and transform care delivery for their most vulnerable and highest-need patients may be more important than ever. Acknowledgments The authors would like to acknowledge all the CHART awardees for their commitment to preserving access to healthcare services in their communities. ajmc.com / 29

6 REFORM TRENDS Author Affiliations: Department of Health Law, Policy and Management (CJL, SSB, DLR), and School of Social Work (SSB), Boston University, Boston, MA; School of Public Health, University of Maryland (DHR), College Park, MA; Massachusetts Health Policy Commission (LM), Boston, MA. Source of Funding: This research was supported through a contract with the Massachusetts Health Policy Commission to evaluate the CHART Phase 2 Investment Program (HPC-RFR ). Author Disclosures: Mrs Melby is an employee of the Massachusetts Health Policy Commission. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Authorship Information: Concept and design (CJL, SSB, DHR, LM, DLR); acquisition of data (CJL, SSB, DLR); analysis and interpretation of data (CJL, DHR, DLR); drafting of the manuscript (CJL, SSB, DHR, LM, DLR); critical revision of the manuscript for important intellectual content (CJL, SSB, DHR, LM, DLR); obtaining funding (CJL); administrative, technical, or logistic support (CJL); and supervision (CJL). Send Correspondence to: Christopher J. Louis, PhD, Boston University School of Public Health, 261W Talbot, Boston, MA louisc@bu.edu. REFERENCES 1. Newhouse JP. Accounting for teaching hospitals higher costs and what to do about them. Health Aff (Millwood). 2003;22(6): doi: /hlthaff Cutler DM, Scott Morton F. s, market share, and consolidation. JAMA. 2013;310(18): doi: /jama Massachusetts health reform: six years later. Kaiser Family Foundation website. kaiserfamilyfoundation.files.wordpress.com/2013/01/8311. pdf. Published May Accessed March 13, Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Ann Intern Med. 2014;160(9): doi: /M National health expenditure data. CMS website. cms.gov/ NationalHealthExpendData. Updated May 5, Accessed March 13, Massachusetts Division of Health Care Finance & Policy. Preventable/avoidable emergency department use in Massachusetts: fiscal years 2004 to State Library of Massachusetts website. archives.lib.state.ma.us/bitstream/handle/2452/50108/ocn pdf?sequence=5. Published July Accessed March 13, Wallack SS, Thomas CP, Flieger SP, Altman SH. Massachusetts health care cost trends part 1: the Massachusetts health care system in context: costs, structure, and methods used by private insurers to pay providers. State Library of Massachusetts website. archives.lib. state.ma.us/bitstream/handle/2452/113728/ocn pdf?sequence=1. Published February Accessed March 17, Mass Gen Laws ch 224, 38C. 9. Health Policy Commission. Massachusetts Executive Office for Administration and Finance website. mass.gov/anf/budget-taxesand-procurement/oversight-agencies/health-policy-commission. Accessed February 12, Massachusetts Health Policy Commission. Community Acceleration, Revitalization, and Transformation (CHART) Phase 1 hospital factbook. Massachusetts Executive Office for Administration and Finance website. mass.gov/anf/budgettaxes-and-procurement/oversight-agencies/health-policycommission/investment-programs/chart/chart-phase-1-factbook. pdf. Published June Accessed October 6, Mass CMR ch 958, Massachusetts Health Policy Commission. The CHART Investment Program overview. Massachusetts Executive Office for Administration and Finance website. mass.gov/anf/budget-taxes-and-procurement/ oversight-agencies/health-policy-commission/investment-programs/ chart/. Updated Accessed October 7, Massachusetts Health Policy Commission. Community Acceleration, Revitalization, & Transformation Investment Program phase 1 investment: foundational activities to prime system transformation. Massachusetts Executive Office for Administration and Finance website. mass.gov/anf/docs/hpc/ chart-phase-1- rfp.pdf. Published October 23, Accessed February 12, Massachusetts Health Policy Commission. CHART Phase 2: driving system transformation. Massachusetts Executive Office for Administration and Finance website. mass.gov/anf/budget-taxesand-procurement/oversight-agencies/health-policy-commission/investment-programs/chart/phase-2/chart-phase-2-rfp-v3-1.pdf. Published June 17, Updated August 6, Accessed February 12, Massachusetts Health Policy Commission. CHART Phase 2 awardees. Massachusetts Executive Office for Administration and Finance website. mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commission/investment-programs/chart/ phase-2/chart-phase-2-award-list.pdf. Accessed October 8, Massachusetts Health Policy Commission. CHART Phase 2 implementation plans. Massachusetts Executive Office for Administration and Finance website. mass.gov/anf/budget-taxesand-procurement/oversight-agencies/health-policy-commission/ investment-programs/chart/chart-phase-2-implementation-plans. html. Updated May 9, Accessed November 6, State Innovation Models initiative: general information. CMS website. innovation.cms.gov/initiatives/state-innovations/. Updated September 14, Accessed March 13, Texas Medical Center Grant Program in Collaborative Health Policy Research. TMC Health Policy website. health-policy/programs/grant-program. Accessed December 12, Value-Based Payment Quality Improvement Program (VBP QIP): frequently asked questions. New York Department of Health website. health. ny.gov/health_care/medicaid/redesign/dsrip/vbp_initiatives/docs/vbp_qip_ faqs.pdf. Published July 13, Accessed December 12, Roby D, Louis CJ, Chau N, et al. Supporting transformation through delivery system reform incentive payment programs: lessons from New York state. J Health Polit Policy Law. In press. 21. MassHealth 1115 waiver approval - factsheet. Massachusetts Executive Office of Health and Human Services website. mass. gov/eohhs/docs/eohhs/healthcare-reform/masshealth-innovations/ ma-1115-waiver-factsheet.pdf. Published November 4, Accessed April 6, / The American Journal of Accountable Care

7 eappendix Table 1. CHART Phase 1 Awards by Funding Amount a Name Project Description Funding Amount Holyoke Medical Center Milford Regional Medical Center Baystate Mary Lane Lowell General Harrington Memorial Athol Memorial Baystate Franklin Medical Center Signature Healthcare Brockton Supports the implementation of an electronic health record in the ED. Supports the piloting of transmission of discharge summaries to select community providers using Mass HIway, integration of process improvements to existing care transitions, reduction of avoidable rehospitalizations programs. Supports the expansion of telemedicine capacities to select inpatient and outpatient specialties, connects local providers to HIEs, and supports evaluation of post-acute services and capabilities in the region. Supports an operational pilot of HIE between the hospital and 1 primary care practice; implementation of HIE connections for 24 practices. Supports local, non-hospital providers in joining the Mass HIway, redesigns the hospital s behavioral health information system, and develops a plan to integrate services. Supports piloting improvements to a school-based health center, improvements in behavioral health case management in the ED, facilitates EHR enhancement, and conducts a telepsychiatry feasibility study. Supports the expansion of telemedicine capacities to select inpatient and outpatient specialties; connects local providers to HIEs. Supports an evaluation of the use of an evidence-based metric for a patient condition, implementation of a provider intelligence tool for community-based population health, and system transformation planning. $500,000 $499,810 $499,600 $497,900 $491,600 $484,128 $476,400 $432,237

8 HealthAlliance Southcoast-Tobey Southcoast-Charlton Memorial North Adams Regional Melrose-Wakefield Southcoast-St. Luke s Lawrence Memorial UMMHC-Wing Memorial hospital Noble Anna Jaques Heywood Supports the enhancement of a patient navigation program to integrate comprehensive behavioral health services across settings and build capacity for HIE. Supports a pilot for inpatient and outpatient diabetes care coordination among high-utilizers. Supports the identification and management of high-risk patients; improves the use of clinical and claims data to enhance population health management. Supports co-location of behavioral health services at primary care practices in the local region. Supports a pilot of revised care plans for patients in the ED with back pain to promote alternatives to opioid use, development of training criteria, and EHR enhancements. Supports the reduction of behavioral health ED visits by creating asset mapping and linkages with community providers, develop protocols and evidence-based medication therapies, and support planning for a medication management clinic for behavioral health Supports a pilot of revised care plans for patients in the ED with back pain to promote alternatives to opioid use, development of training criteria, and EHR enhancements. Supports the achievement of Meaningful Use Stage 1 compliance. Supports the development of centralized scheduling hub to coordinate appointments across multiple hospital units; support planning for HIE connectivity. Supports training of managers and clinical leaders in change management; implements a tool used to facilitate communication with post-acute providers; and implements a tool used to support enhanced monitoring of care. Supports the expansion of behavioral health navigation, evaluate the feasibility of a school-based health center, $410,000 $400,100 $397,862 $395,311 $387,302 $385,395 $362,058 $357,000 $344,665 $333,500 $316,384

9 Beth Israel Deaconess- Needham Addison Gilbert Winchester Beth Israel Deaconess- Milton Jordan Mercy Medical Center connect a local medical group to the Mass HIway, and strategic planning for behavioral health services. Supports the identification of high-risk patients covered under risk contracts, expanded case management services and automated system for tracking adverse events. Supports implementation of a High Risk Intervention Team that provides patient education, medication management, and discharge planning to patients with certain complex chronic illnesses. Supports care management services and enhanced transitions to skilled nursing facilities with the goal of reducing re-hospitalizations. Increases access to language services for Vietnamesespeaking patients (including the use of health information technology, patient navigation, and signage and communication materials). Supports the expansion of a case management program for medically-complex and chronically ill patients (focusing on dual-eligibles and end-stage renal disease). Supports the development of organizational capabilities, capacities, and culture change to sustain continuous quality and safety improvements. $300,000 $291,581 $286,500 $261,200 $245,818 $223,134 Emerson Supports HIE across care settings. $202,575 Lawrence General Beverly Supports a needs assessment of care management software targeted toward clinical information flow between the hospital and community providers, and coordination of activities related to care transitions. Supports the strategic and operational planning to reduce hospital utilization for cardiovascular issues and readmissions for certain $100,000 $65,000 CHART indicates Community Acceleration, Revitalization and Transformation; ED, emergency department; EHR, electronic health record; HIE, health information exchange.

10 a Adapted from: Commonwealth of Massachusetts Health Policy Commission CHART Phase 1 Awardees. Massachusetts Executive Office for Administration and Finance website. Published January 8, Accessed October 7, 2016.

11 eappendix Table 2. CHART Phase 2 Awards by Funding Amount Name Project Description a Primary Project Aim Statement b Funding Amount Southcoast s Group (Charlton, Tobey, & St. Luke s) Joint Award c Support a variety of population health management initiatives among several chronic and acute disease management activities, including BH. 1. Reduce 30-day readmissions by 20% for patients with 4 inpatient discharges in the past 12 months, by the end of the 24-month 2. Reduce 30-day ED revisits by 20% for patients with 10 ED visits in the past 12 months, by the end of the 24-month Measurement Period. $8,000,000 Addison Gilbert, Beverly, Winchester, & Lowell Joint Award c Support mobile crisis and urgent care teams, integrate behavioral health services into EDs, and launch a BH public education campaign. Reduce 30-day returns by 20% for patients with a personal history of recurrent acute care utilization, social complexity (substance use disorder, Medicaid, homeless, or Medicare <65 years), or a 30-day readmission by the end of the 24- month $4,800,000 Holyoke Medical Center Support enhancement of the ED to support BH care and the creation of a care navigation team. Reduce 30-day ED revisits by 25% for patients with a primary or secondary BH diagnosis. by the end of the 24-month Measurement Period. $3,900,000 HealthAlliance Support care coordination infrastructure to enhance BH care and reduce ED utilization and length of stay. Reduce 30-day ED revisits by 15% for patients with a primary and/or secondary BH diagnosis by the end of the 24-month Measurement Period. $3,800,000 Beth Israel Deaconess - Plymouth Support the improvement of access to services for complex patient populations through (1) formation of a high-risk care team, (2) co-locating BH practitioners in ED and PCP offices, 1. Reduce returns by 10% for dual eligible patients by the end of the 24-month $3,700,000

12 and (3) outreach teams for community education and outpatient substance use treatment. 2. Reduce ED revisits by 20% for patients with primary BH diagnoses by the end of the 24- month Harrington Memorial Support cross-continuum BH services through PCP-based screening and intervention, expansion of partial hospitalization, and creation of a new inpatient psychiatry unit. Reduce 30-day ED revisits by 15% for adult patients with a primary or secondary BH diagnosis by the end of the 24-month Measurement Period. $3,500,000 Signature Healthcare Brockton 1. Reduce 30-day readmissions by 20% for all admitted patients (excluding patients served by DSTI) by the end of the 24-month 2. Reduce the length of stay by 15% in the ED s 3 PM -11 PM Express Care shift by the end of the 24-month $3,500,000 Berkshire Medical Center Develop a patient-centered medical neighborhood and enhance BH care for the region. Reduce 30-day returns by 20% for all inpatient and observation discharges of Northern Berkshire County residents by the end of the 24-month $3,000,000 Heywood & Athol Joint Award c Support planning for increasing inpatient and outpatient BH services at a newly acquired property; support multidisciplinary BH initiatives, including ED and physician office care teams, school-based coordination and mental health counseling, and a shared directory of community and clinical resources. Reduce 30-day ED revisits by 10% for patients with any BH diagnosis by the end of the 24-month $2,900,000 Beverly Reduce 30-day returns by 20% for patients with a personal history of recurrent acute care utilization, social complexity (substance use $2,500,000

13 disorder, Medicaid, homeless, or Medicare <65 years), or a 30-day readmission by the end of the 24- month Hallmark Health (Melrose- Wakefield & Lawrence) Joint Award c Support the development and implementation of a high-utilizer multidisciplinary outreach team with a BH focus, particularly around pain management and opioid prevention, in community-based sites. Reduce ED utilization by 20% for all ED HU patients by the end of the 24-month $2,500,000 Beth Israel Deaconess - Milton Support the delivery of integrated emergency BH services through telepsychiatry, early assessment of BH patients, and advanced predictive analytics. Reduce excess ED boarding by 40% for long-stay BH patients by the end of the 24-month $2,000,000 Baystate Franklin Medical Center patients; award also funds cross-setting coordination of screening, intervention, and support for patients with complex BH conditions. Reduce 30-day ED revisits by 25% for patients with 5 BH ED visits (primary or secondary) or 4 inpatient stays in the last year by the end of the 24-month $1,800,000 Lawrence General Reduce 30-day readmissions by 20% for patients with social and/or medical complexity by the end of the 24-month $1,482,654 Mercy Medical Center Reduce 30-day ED revisits by 20% for patients with a primary BH diagnosis by the end of the 24- month $1,300,000 Milford Regional Medical Center Reduce 30-day readmissions by 25% for patients with 3 inpatient discharges in the last year by the end of the 24-month Measurement Period. $1,300,000

14 Addison Gilbert Reduce 30-day returns by 20% for patients with a personal history of recurrent acute care utilization, social complexity (substance use disorder, Medicaid, homeless, or Medicare <65 years), or a 30-day readmission by the end of the 24- month $1,269,057 Anna Jacques Reduce 30-day readmissions by 20% for patients with high utilization of the hospital and ED by the end of the 24-month $1,200,000 Emerson Reduce 30-day returns by 20% for all medical/surgical/bh patients with a high risk of readmission by the end of the 24-month $1,200,000 Marlborough Reduce 30-day readmissions by 15% for patients with 4 discharges in the prior 12 months or patients with 10 ED visits and/or 5 BH ED visits in the prior 12 months by the end of the 24- month $1,200,000 Baystate Noble Reduce 30-day readmissions by 25% for patients discharged to SNF and HU of the ED and/or hospital by the end of the 24-month $1,200,000 Baystate Wing Reduce 30-day readmissions by 20% for patients with life-limiting conditions and/or BH diagnosis by the end of the 24-month $1,000,000

15 Lowell General Reduce 30-day readmissions by 20% for patients with 4 inpatient discharges in the previous 12 months by the end of the 24-month $1,000,000 Winchester 1. Reduce 30-day readmissions by 20% for patients with high utilization by the end of the 24- month 2. Reduce 30-day readmissions by 20% for all patients discharged to post-acute care by the end of the 24-month $1,000,000 Baystate Franklin, Baystate Mary Lane, & Baystate Wing Joint Award c Support the enhancement of telehealth services across the system to maximize retention of patients in select service lines in community settings. Reduce lower acuity (Severity 1 & 2) adult tertiary transfers for medically-focused neurosciences, adult medicine, and cardiovascular services by 20%, by the end of the 24-month $900,000 BH indicates behavioral health; CHART, Community Acceleration, Revitalization and Transformation; DSTI, Delivery System Transformation Initiative; ED, emergency department; HU, high utilizer; PCP, primary care physician; SNF, skilled nursing facility. a Adapted from: Commonwealth of Massachusetts Health Policy Commission. CHART Phase 2 awardees. Massachusetts Executive Office for Administration and Finance website. Accessed October 8, b Primary project aim statements taken from the CHART Phase 2 awardee implementation plans (revised as of June 2016). c Joint awards consist of multiple hospitals collaborating to perform the same or similar projects at each hospital. Dollars are distributed to each hospital involved in the joint award.